| NPI | 1083771190 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 208600000X Surgery (Licence: MI 4301078502) | 
| Additional Taxonomies | 261Q00000X Clinic/Center (Licence: MI 4301078502) | 
| 261QU0200X Clinic/Center, Urgent Care (Licence: MI 4301078502) | |
| Enumeration Date | 2007-01-02 | 
| Last Update Date | 2013-03-15 |